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To compare the cost-benefit of active surveillance (AS) against immediate fine needle aspiration (FNA) of sonographically suspicious sub-centimeter thyroid nodules.A Markov model was constructed to compare the cost-benefit of three strategies from point of discovery till death: 1) Surveillance of All Nodules; 2) Surveillance of Nodules with Positive Cytology; and 3) Surgery of Nodules with Positive Cytology. The reference case was a 40 year-old female with a sonographically suspicious sub-centimeter thyroid nodule. Transition probabilities, costs, and health utilities were derived from the literature. Sensitivity analyses were performed to evaluate model uncertainty. Willingness-to-pay threshold was set at $100,000/quality-adjusted life year (QALY).Surveillance of Nodules with Positive Cytology dominated in the reference scenario, and was cost-beneficial over Surveillance of All Nodules independent of the utility of AS. Surveillance of All Nodules was cost-beneficial only at life expectancy2.6 years or surveillance duration4 years.While current guidelines recommend AS of sonographically suspicious sub-centimeter nodules, this study's results suggest immediate FNA (Surveillance of Nodules with Positive Cytology) is more cost-beneficial compared to AS (Surveillance of All Nodules). Patients with positive cytology on FNA may subsequently opt for AS (Surveillance of Nodules with Positive Cytology) or surgery (Surgery of Nodules with Positive Cytology) according to their level of comfort (i.e. utility) with AS.

This study aimed to determine the cost-effectiveness of drug-coated balloon (DCB) angioplasty compared with conventional balloon angioplasty (cPTA) in patients with arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) dysfunction from a Singapore healthcare perspective.Existing cost-effectiveness studies comparing DCB and cPTA have not incorporated AVF/AVG abandonment costs. This Markov model-based economic evaluation incorporated AVF/AVG creation and maturation costs on top of routine intervention costs to model a hypothetical cohort of 60-year-old AVF/AVG flow dysfunction patients. Effectiveness was measured in quality-adjusted life-years. Cost-effectiveness was assessed using incremental net monetary benefit (NMB) at a Singapore willingness-to-pay threshold of Singapore dollar (S$)87 000. Deterministic and probabilistic sensitivity analyses were performed to examine parameter uncertainty. To test hypotheses regarding cost-effectiveness, intervention counts per patient, cumulative incidence functions of AVF/AVG abandonment, and survival curves of death were compared between DCB and cPTA.DCB was not cost-effective at 3-year horizon (NMB = -S$1424), but was cost-effective at 1- and 6-year horizons (NMB = S$356 and S$3738, respectively). At 3 years, there was a 34.5% probability of DCB being cost-effective, but at 1- and 6-year horizons there was, respectively, 58.6% and 59.9% probability of DCB being cost-effective. DCB had graphically less AVF/AVG-abandonments, but this was not statistically significant (P = .21). Differences in other parameters were neither graphically nor statistically significant.With AVF/AVG abandonment considered, DCB may be weakly cost-effective compared with cPTA in treating AVF/AVG flow dysfunction. AV access creation and maturation costs could have important explanatory value in assessing DCB cost-effectiveness.

Purpose:Despite the established role of EGFR tyrosine kinase inhibitors (TKIs) in EGFR-mutated NSCLC, drug resistance inevitably ensues, with a paucity of treatment options especially in EGFRT790M-negative resistance.Experimental Design:We performed whole-exome and transcriptome analysis of 59 patients with first- and second-generation EGFR TKI-resistant metastatic EGFR-mutated NSCLC to characterize and compare molecular alterations mediating resistance in T790M-positive (T790M+) and -negative (T790M−) disease.Results:Transcriptomic analysis revealed ubiquitous loss of adenocarcinoma lineage gene expression in T790M− tumors, orthogonally validated using multiplex IHC. There was enrichment of genomic features such as TP53 alterations, 3q chromosomal amplifications, whole-genome doubling and nonaging mutational signatures in T790M− tumors. Almost half of resistant tumors were further classified as immunehot, with clinical outcomes conditional on immune cell-infiltration state and T790M status. Finally, using a Bayesian statistical approach, we explored how T790M− and T790M+ disease might be predicted using comprehensive genomic and transcriptomic profiles of treatment-naïve patients.Conclusions:Our results illustrate the interplay between genetic alterations, cell lineage plasticity, and immune microenvironment in shaping divergent TKI resistance and outcome trajectories in EGFR-mutated NSCLC. Genomic and transcriptomic profiling may facilitate the design of bespoke therapeutic approaches tailored to a tumor's adaptive potential.

Supplementary Data from Integrative Profiling of T790M-Negative EGFR-Mutated NSCLC Reveals Pervasive Lineage Transition and Therapeutic Opportunities

Drug-coated balloon angioplasty (DCBA) has been studied as a potentially superior option compared to conventional percutaneous transluminal angioplasty (PTA) in treating below-the-knee (BTK) arteries in chronic limb-threatening ischemia (CLTI). The aim of this study is to examine the cost-effectiveness of DCBA versus PTA in BTK arteries based on a randomized controlled trial.A prospective economic study was embedded in a randomized controlled trial of 138 patients with CLTI. Resource use and health outcomes were assessed at baseline, and at 3, 6 and 12 months post-intervention. Costs were calculated from a societal perspective and health outcomes measured using quality-adjusted life years with probabilistic sensitivity analysis performed to account for subject heterogeneity.Compared with participants randomized to receive PTA, participants randomized to DCBA gained an average baseline-adjusted quality-adjusted life years (QALYs) of .012 while average total costs were USD$1854 higher; this translates to an incremental cost-effectiveness ratio (ICER) of US$154,500 additional cost per QALY gained. However, the estimate of ICER had substantial variance with only 48% of bootstrap ICERs meeting a benchmark threshold of US$57,705 (the average gross domestic product (GDP) per capita of Singapore).The use of DCBA in BTK arteries in CLTI patients was not cost-effective compared with PTA.2, Randomized trial.

To study the safety and efficacy of cutting balloon angioplasty (CBA) followed by paclitaxel drug-coated balloon (PCB) angioplasty for recurrent venous lesions in arteriovenous fistulas (AVFs).We conducted a prospective single-arm cohort study of CBA followed by PCB angioplasty for recurrent AVF stenoses between September 2017 and April 2019. In total, 44 participants were recruited. Target lesions were included if they had recurred within 12 months post-angioplasty, were = 0.5 cm upstream from the arteriovenous anastomosis, and did not involve the central veins. Up to two non-target lesions per circuit/participant with the same definition were allowed. Lesions were considered separate when there was an intervening 2-cm segment of normal vessel. Technical success was defined as complete lesion effacement on angioplasty. End-points of target and circuit patency were evaluated clinically at 3, 6, and 12 months post-procedure.Technical success was 96% (42/44): Two participants were excluded from analysis due to the need for high-pressure balloon angioplasty as the target lesions did not efface with CBA. The median follow-up duration was 337.5 days. Mean stenosis pre- and post-angioplasty was 69.0% (51.6-84.8) and 20.8% (0-44.8), respectively. The target lesion primary, primary assisted and circuit patency for the entire study population (n = 42) were 61.6 ± 7.8%, 92.7 ± 4.0%, and 54.7 ± 7.9%, respectively, at 12 months. For participants without non-target lesions (n = 22), the rates were 77.3 ± 8.9%, 90.9 ± 6.1%, and 60.7 ± 11.0%, respectively, at 12 months.CBA followed by PCB angioplasty appears safe and feasible for treatment of recurrent venous lesions in dysfunctional AVFs.

PURPOSE Precision oncology has transformed the management of advanced cancers through implementation of advanced molecular profiling technologies to identify increasingly defined subsets of patients and match them to appropriate therapy. We report outcomes of a prospective molecular profiling study in a high-volume Asian tertiary cancer center. PATIENTS AND METHODS Patients with advanced cancer were enrolled onto a prospective protocol for genomic profiling, the Individualized Molecular Profiling for Allocation to Clinical Trials Singapore study, at the National Cancer Center Singapore. Primary objective was to identify molecular biomarkers in patient's tumors for allocation to clinical trials. The study commenced in February 2012 and is ongoing, with the results of all patients who underwent multiplex next-generation sequencing (NGS) testing until December 2018 presented here. The results were discussed at a molecular tumor board where recommendations for allocation to biomarker-directed trials or targeted therapies were made. RESULTS One thousand fifteen patients were enrolled with a median age of 58 years (range 20-83 years). Most common tumor types were lung adenocarcinoma (26%), colorectal cancer (15%), and breast cancer (12%). A total of 1,064 NGS assays were performed, on fresh tumor tissue for 369 (35%) and archival tumor tissue for 687 (65%) assays. TP53 (39%) alterations were most common, followed by EGFR (21%), KRAS (14%), and PIK3CA (10%). Of 405 NGS assays with potentially actionable alterations, 111 (27%) were allocated to a clinical trial after molecular tumor board and 20 (4.9%) were enrolled on a molecularly matched clinical trial. Gene fusions were detected in 23 of 311 (7%) patients tested, including rare fusions in new tumor types and known fusions in rare tumors. CONCLUSION Individualized Molecular Profiling for Allocation to Clinical Trials Singapore demonstrates the feasibility of a prospective broad molecular profiling program in an Asian tertiary cancer center, with the ability to develop and adapt to a dynamic landscape of precision oncology.

To perform an individual patient data level meta-analysis of randomised controlled trials comparing drug coated balloon angioplasty (DCB) against conventional percutaneous transluminal angioplasty (PTA) in the treatment of dysfunctional haemodialysis venous access.A search was conducted from inception to 13 November 2020. Kaplan-Meier curves comparing DCB with PTA by target lesion primary patency (TLPP) and access circuit primary patency (ACPP) were graphically reconstructed to retrieve patient level data. One stage meta-analyses with Cox models with random effects shared frailties were conducted to determine hazard ratios (HRs). Dynamic restricted mean survival times (RMST) were conducted in view of violation of the proportional hazards assumption. Conventional two stage meta-analyses and network meta-analyses under random effects Frequentist models were conducted to determine overall and comparative outcomes of paclitaxel concentrations used. Where outliers were consistently detected through outlier and influence analyses, sensitivity analyses excluding those studies were conducted.Among 10 RCTs (1 207 patients), HRs across all models favoured DCB (one stage shared frailty HR 0.62, 95% CI 0.53 - 0.73, p.001; two stage random effects HR 0.60, 95% CI 0.42 - 0.86, p = .018, IOverall evidence suggests that DCB is favoured over PTA in TLPP and ACPP.

An 84-year-old female with metastatic left breast cancer underwent a venous port insertion for chemotherapy. The port was inserted using standard techniques with image guidance under local anesthesia. She presented after 36 days with evidence of infection. A limited bedside ultrasound demonstrated free fluid surrounding the port. The port was subsequently removed the same day, at which time pus was expressed from the subcutaneous pocket. The culture from the pus grew Mycobacterium abscessus. She required removal of the port and wound debridement, wound dressings and a prolonged course of antibiotics. Mycobacterium abscessus is a group of rapidly growing, multidrug-resistant, non-tuberculous mycobacteria that are also relatively resistant to standard skin disinfectants. In recent years, this organism has been increasingly reported as the culprit in post-operative or post-procedural infections. Treatment is challenging due to multidrug resistance, and requires an extensive course of intravenous antimicrobial and macrolide-based combination therapy followed by oral antimicrobial therapy. Early treatment is essential as progression may result in disseminated infection. We discuss the peri-operative and post-operative care required in preventing and treating infection with this organism.

Severe acute respiratory syndrome coronavirus 2 has spread across the world since December 2019, infecting 100 million and killing millions. The impact on health care institutions during the coronavirus disease 2019 pandemic has been considerable, with exhaustion of institutional and personal protective equipment resources during local outbreaks and crushing financial consequences for many institutions. Establishing adaptive principles of leadership is necessary during crises, fostering quick decision-making and workflow modifications, while a rapid review of data must determine necessary course corrections. This report describes concepts of crisis leadership teams that can help maximize their effectiveness during the current and future pandemics. © RSNA, 2021

The coronavirus disease 2019 (COVID-19) pandemic resulted in widespread disruption to the global economy, including demand for imaging services. The resulting reduction in demand for imaging services had an abrupt and substantial impact on private radiology practices, which are heavily dependent on examination volumes for practice revenues. The goal of this article is to describe the specific experiences of radiologists working in various types of private radiology practices during the initial peak of the COVID-19 pandemic. Herein, the authors describe factors determining the impact of the pandemic on private practices, the challenges these practices have faced, the cost levers leaders adjusted, and the government subsidies sought. In addition, the authors describe adjustments practices are making to their mid- and long-term strategic plans to pivot for long-term success while managing the COVID-19 pandemic. Private practices have crafted tiered strategies to respond to the impact of the pandemic by pulling various cost levers to adjust service availability, staffing, compensation, benefits, time off, and expense reductions. In addition, they have sought additional revenues, within the boundaries of their practice, to mitigate ongoing financial losses. The longer-term impact of the pandemic will alter existing practices, making some of them more likely than others to succeed in the years ahead. This report synthesizes the collective experience of private practice radiologists shared with members of the Radiological Society of North America (RSNA) COVID-19 Task Force, including discussions with colleagues and leaders of private practice radiology groups from across the United States.

To describe rates and management strategies of arterial dissections in transarterial chemoembolization (TACE) and Yttrium-90 selective internal radiotherapy (90Y SIRT) for primary and secondary liver tumours. This retrospective review included 1377 hepatic angiographies between May 2010 and June 2015 in a single centre for TACE and 90Y SIRT of liver tumours. The angiogram results, management, treatment outcomes and follow-up angiography/imaging findings were recorded. Twelve cases of arterial dissections (12/1377, 0.87%) were documented. Three dissections (3/633, 0.47%) occurred during TACE, seven (7/449, 1.56%) during pre-treatment planning angiographies (PTPA) for 90Y SIRT, and two (2/249, 0.80%) during the treatment procedure of 90Y SIRT. The preferred management strategy was to manoeuvre past the dissection and complete the procedure, which was achieved in six patients (50%). Angioplasty with stenting was performed in one patient. In three patients, the procedure was held off for up to 3 months to allow the dissection to heal before repeating the procedure. A dissection that occurred during PTPA was detected only when the patient returned for 90Y SIRT. PTPA was immediately repeated for this patient. The last patient opted for sorafenib. Residual 50% stenosis was seen in one patient on follow-up hepatic angiography, but he was otherwise asymptomatic. In the remaining patients, no residual dissection or clinical sequelae was observed on follow-up. Arterial dissection is a rare but important complication of transarterial locoregional therapy. Where possible, attempts should be made at completing the therapy. Deferring treatment can be considered as dissections usually heal within 3 months. Level 4, case series.

Author(s): Mossa-Basha, Mahmud; Meltzer, Carolyn C; Kim, Danny C; Tuite, Michael J; Kolli, K Pallav; Tan, Bien Soo

Introduction: To evaluate the mid-term outcomes of regular surveillance venography with or without percutaneous transluminal angioplasty in haemodialysis patients presenting with central venous occlusive disease. Materials and Methods: A single-centre retrospective analysis of haemodialysis patients who presented with central vein occlusion (CVO) and central vein stenosis (CVS) between January 2008 and December 2011 was performed. CVO and significant CVS were defined as 100% and >50% luminal narrowing respectively. Upon successful angioplasty on first presentation, patients were followed up with regular surveillance venography within 3–6 months of the intervention and were re-treated when a significant stenosis or occlusion was demonstrated. Data on patient’s demographics, comorbidities, presenting symptoms, type of upper limb dialysis access, lesion characteristics and complications were collected. Technical success, primary patency and primary assisted patency were analysed. Results: Thirty-five patients with CVO and 77 patients with CVS were enrolled. The technical success of initial PTA was 77% and 73% for the CVO and CVS groups, respectively. The primary patency at 3 months was 65% and 55% for the CVO group and CVS group, respectively (P = 0.32). The primary assisted patency at 1 year was 88% and 99% for the CVO group and CVS group, respectively (P = 0.009). At 2 years, the primary assisted patency were 77% and 90%, respectively (P = 0.07). There was significant difference in the overall primary assisted patency (P = 0.048) between the CVO and CVS groups. Conclusion: CVOs are more difficult to treat than CVS. High primary assisted patency rates can be achieved with surveillance venography, albeit at the expense of increased number of interventions. Further cost effectiveness studies need to be performed to study the true benefit of our surveillance programme. Ann Acad Med Singapore 2020;49:360–66 Key words: Dialysis circuit, End stage renal failure, Renal replacement therapy

In the era of COVID-19, “social distancing” has become a buzzword. Strictly speaking, social distancing refers to physically distancing by 1 to 2 m, but the overall concept is more important: disrupting the infectious chain by separating those with the disease from those without [1]. Epidemiologists have espoused the term, believing in its ability to “flatten the curve.” By reducing the exponential rise in cases, the health care system is not overwhelmed and can function sustainably over the long term [1]. Although this concept’s main intention is to control disease, in the hospital setting, it provides the equally important added benefit of ensuring continuity of vital services should intrahospital transmission occur [2]. We are part of a 1,700-bed hospital, with a radiological service strength of over 600 (41 residents, 77 attending physicians [nuclear medicine, interventional, diagnostic], 273 radiographers, and 240 nurses and administrative support staff). This article describes our measures and early experiences with safe distancing in our radiology service.

This paper describes country-wide special measures undertaken for interventional radiology staff during the current coronavirus disease 2019 (COVID-19) pandemic. Although each interventional radiology service around the world faces unique challenges, the principles outlined in this article will be useful when designing or strengthening individual practices and integrating them within wider hospital and national measures. Moving beyond the current outbreak, these measures will be useful for any future infectious diseases which are likely to arise.

With astonishing speed, COVID-19 has become a global pandemic. As it is uncertain when the pandemic will be controlled, it is crucial for procedurists of all stripes to be familiar and confident in performing procedures for COVID-19 patients to prevent intra-hospital infection. In this article, we will detail our approach on how to perform interventional procedures for COVID-19 patients at the bedside in the isolation room and with the patient transferred to the interventional radiology centre. These workflows have been developed in conjunction with multiple other stakeholders within our hospital, drawing from valuable lessons we have learnt from the SARS outbreak of 2003.

Purpose To report the outcome and distal access patency of the Subintimal Arterial Flossing with Antegrade-Retrograde Intervention (SAFARI) technique for chronic total occlusion (CTO) in critical limb ischemia (CLI). Materials and Methods From January 2009 to June 2015, 220 SAFARI procedures were performed for 200 limbs in 191 patients (108 males [56.5%]; median age, 70 years old; range, 36 to 97 years old) with CLI (9.4% were Fontaine classification 3; and 90.6% were Fontaine classification 4). Distal access was obtained from the distal superficial femoral artery (n = 6), popliteal artery (n = 49), anterior tibial artery (n = 56), dorsalis pedis (n = 51), peroneal artery (n = 12), posterior tibial artery (n = 45), and lateral plantar artery (n = 1). Distal access hemostasis was obtained with internal balloon tamponade in 71.4% (n = 157). Outcome measurements were technical success, freedom from major amputation and complications. Preprocedural angiograms of clinically driven repeat interventions were reviewed in 73 cases for distal access patency. Results Technical success was achieved in 80.5% (n = 177). Reasons for technical failure include inability to obtain distal access (n = 3), cross the occlusion retrogradely (n = 16), re-enter the true lumen (n = 9), and achieve antegrade blood flow after the procedure (n = 15). Freedom from major amputation for technically successful procedures was 84.7%, 82.9%, and 81.9% at 6, 12, and 24 months, respectively. There were 3 cases of distal access bleeding with 1case that required coil embolization. The distal access remained patent in 80.8% of observable cases with repeated endovascular intervention. Conclusions Distal retrograde arterial access (SAFARI) technique is safe and effective in the treatment of CTOs in the context of CLI, after failure of antegrade revascularization.

Objectives There is an expanding list of therapeutically relevant biomarkers for non-small cell lung cancer (NSCLC), and molecular profiling at diagnosis is paramount. Tissue attrition in scaling traditional single biomarker assays from small biopsies is an increasingly encountered problem. We sought to compare the performance of targeted next-generation sequencing (NGS) panels with traditional assays and correlate the mutational landscape with PD-L1 status in Singaporean patients. Materials and methods We identified consecutive patients diagnosed between Jan 2016 to Sep 2017 with residual tissue after standard molecular testing. Tissue samples were tested using a targeted NGS panel for DNA alterations (29 selected genes including BRAF, EGFR, ERBB2 and TP53) and an RNA fusion panel (ALK, ROS1 and RET). PD-L1 immunohistochemistry was also performed. A cost-effectiveness analysis of NGS compared to standard molecular testing was conducted. Results A total of 174 samples were evaluated: PD-L1 (n = 169), NGS DNA panel (n = 173) and RNA fusion (n = 119) testing. Median age was 68 years, 53 % were male, 58 % were never smokers, 85 % were Chinese, 66 % had stage IV disease and 95 % had adenocarcinoma histology. In patients profiled with NGS on DNA, EGFR (56 %), KRAS (14 %), BRAF (2 %) and ERBB2 (1 %) mutations were found. RNA fusion testing revealed fusions in ALK (6 %), RET (3 %) and ROS1 (1 %). Cost-effectiveness analysis demonstrated that compared to sequential testing in EGFR negative patients, upfront NGS testing would result in an additional 1 % of patients with actionable alterations for targeted therapy being identified without significant increases in testing cost or turnaround time. Conclusions This study demonstrates that even in an EGFR mutant predominant population, upfront NGS represents a feasible, cost-effective method of diagnostic molecular profiling compared with sequential testing strategies. Our results support the implementation of diagnostic NGS in non-squamous NSCLC in Asia to allow patients access to the most appropriate personalized therapy.

Background Percutaneous transluminal angioplasty is the current standard treatment for arteriovenous fistula (AVF) stenosis. The mid- and long-term patency with plain balloon angioplasty (PBA) is however far from satisfactory. While paclitaxel-coated balloon angioplasty has been shown to be superior to PBA, concern over its safety profile has recently arisen after a reported possible increased mortality risk with a meta-analysis of large lower limb studies. An angioplasty balloon with a new type of drug coating, the sirolimus-coated balloon (SCB), has been proven to improve patency in the coronary arteries. However, its effect on AV access has yet to be studied. Methods/design This is an investigator-initiated, prospective, multicenter, double-blinded, randomized controlled clinical trial to assess the effectiveness of SCB compared to PBA in improving the patency of AVF after angioplasty. A total of 170 patients with mature AVF that requires PTA due to AVF dysfunction will be randomly assigned to treatment with a SCB or PBA at a 1:1 ratio, stratified by location of AVF and followed up for up to 1 year. The inclusion criteria include [1] adult patient aged 21 to 85 years who requires balloon angioplasty for dysfunctional arteriovenous fistula [2]; matured AVF, defined as being in use for at least 1 month prior to the angioplasty; and [3] successful angioplasty of the underlying stenosis with PBA, defined as less than 30% residual stenosis on digital subtraction angiography (DSA) and restoration of thrill in the AVF on clinical examination. The exclusion criteria include thrombosed or partially thrombosed access circuit at the time of treatment, presence of symptomatic or angiographically significant central vein stenosis that requires treatment with more than 30% residual stenosis post angioplasty, and existing stent placement within the AVF circuit. The primary endpoint of the study is access circuit primary patency at 6 months. The secondary endpoints are target lesion primary patency; access circuit-assisted primary patency; access circuit secondary patency at 3, 6, and 12 months; target lesion restenosis rate at 6 months; total number of interventions; complication rate; and cost-effectiveness. The trial is supported by Concept Medical. Discussion This study will evaluate the clinical efficacy and safety of SCB compared to PBA in the treatment of AVF stenosis in hemodialysis patients. Trial registration ClinicalTrials.govNCT04409912. Registered on 1 June 2020

acceptedVersion

Access to imaging diagnostics has been shown to result in accurate treatment, management, and optimal outcomes. Particularly in low-income and low-middle-income countries (LICs, LMICs), access is limited due to a lack of adequate resources. To achieve Sustainable Development Goal (SDG) 3, access to imaging services is critical at every tier of the health system. Optimizing imaging services in low-resource settings is best accomplished by prescriptive, integrated, and coordinated tiered service delivery that takes contextual factors into consideration. To our knowledge, this is the first recommendation for optimized, specific imaging care delivery by tier. A model for tier-based essential imaging services informs and guides policymakers as they set priorities and make budgetary decisions. In this paper, we recommend a framework for tiered imaging services essential to reduce the global burden of disease and attain universal health coverage (UHC). A lack of access to basic imaging services, even at the lowest tier of the health system, can no longer be justified by cost. Worldwide, affordable modalities of modern ultrasound and X-ray are becoming an accessible mainstay for the investigation of common conditions such as pregnancy, pneumonia, and fractures, and are safely performed and interpreted by qualified professionals. Finally, given the vast gap in access to imaging resources between LMICs and high-income countries (HICs), a scale-up of tiered imaging services in low-resource settings has the potential to reduce health disparities between, and within countries. As the access to appropriately integrated imaging services improves, UHC may be achieved.

Background There is a paucity of randomized trials demonstrating superior efficacy of drug-coated balloon angioplasty (DCBA) compared with conventional percutaneous transluminal angioplasty (PTA) for below-the-knee arterial disease in patients with -critical limb ischemia. Purpose To compare DCBA versus PTA for below-the-knee lesions in participants with critical limb ischemia through 12 months. Materials and Methods In this prospective, randomized, two-center, double-blind superiority study, participants with critical limb ischemia with rest pain or tissue loss with atherosclerotic disease in the native below-the-knee arteries were randomly assigned (in a one-to-one ratio) to DCBA or PTA after stratification for diabetes and renal failure between November 2013 and October 2017. The primary efficacy end point was angiographic primary patency at 6 months analyzed on an intention-to-treat basis. Secondary end points through 12 months were composed of major adverse events including death and major amputations, wound healing, limb salvage, clinically driven target-lesion revascularization, and amputation-free survival. Primary and binary secondary end points, analyzed by using generalized-linear model and time-to-event analyses, were estimated with Kaplan-Meier survival curves and hazard ratios (Cox regression). Results Seventy participants (mean age, 61 years ± 10 [standard deviation]; 43 men) in the DCBA group and 68 (mean age, 64 years ± 10; 50 men) in the PTA group were evaluated. The percentage of patients with angiographic primary patency at 6 months was 43% (30 of 70) in the DCBA group and 38% (26 of 68) in the PTA group (P = .48). Through 12 months, the percentage of deaths was similar: 21% in the DCBA group and 16% in the PTA group (P = .43). Amputation-free survival rate assessed with Kaplan-Meier curves differed through 12 months: 59% (41 of 70) in the DCBA group compared with 78% (53 of 68) in the PTA group (P = .01). Conclusion In participants with critical limb ischemia, the drug-coated balloon angioplasty group and the conventional percutaneous transluminal angioplasty group had similar primary patency rates at 6 months after treatment of below-the-knee arteries. Amputation-free survival rates through 12 months were higher in the percutaneous transluminal angioplasty group. © RSNA, 2021 Online supplemental material is available for this article.

RATIONALE AND OBJECTIVES: Lack of uniformity in radiology resident education is partially attributable to variable access to subspecialty education. Web-based courses improve standardization, but with growing emphasis on competency-based education, more evaluation of their effectiveness is needed. We created a responsive web-based breast imaging curriculum for radiology residents including self-assessment and a satisfaction survey. MATERIALS AND METHODS: Two global academic institutions collaboratively developed a breast imaging curriculum to address radiology residents’ educational needs. This virtual course comprised 11 video lectures, nine didactic (with attached pre-test and post-test assessments) and two case review sessions. In April 2020, this optional curriculum was made available to all 56 radiology residents in one residency program cluster in Singapore, to be accessed alongside the breast imaging rotation as a supplement. A voluntary anonymous satisfaction survey was provided upon completion. RESULTS: 39 of the 56 radiology residents (70%) completed the course. For the average score of Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation nine lectures (maximum score 5), there was a significant increase in mean pre- and post-test scores (mean = 2.2, SD = 0.7), p < .001. The proportion of residents with improvement between the pre-test score and the post-test score ranged from 74% to 100% (mean, 84%). Thirty- three of the 39 participants (85%) completed the satisfaction survey, and all agreed or strongly agreed that the curriculum increased their knowledge of breast imaging. CONCLUSION: This web-based breast imaging curriculum supplement was viewed positively by participating residents and improved their self-assessed knowledge. Curriculum access could be expanded to improve global radiology education.

BACKGROUND The management of thyroid nodules ≥ 4 cm is controversial due to conflicting evidence on the prevalence of malignancy and diagnostic accuracy of fine-needle aspiration cytology (FNAC). Some literature recommends routine excision of large thyroid nodules due to high cytology false negative rates (FNR). We aim to investigate the diagnostic accuracy of FNAC, prevalence of malignancy in large (≥ 4 cm) thyroid nodules compared to nodules

To determine the rate of prophylactic embolization of extrahepatic vessels in patients undergoing yttrium-90 selective internal radiotherapy (90Y SIRT) for hepatocellular carcinoma (HCC) with the use of catheter-directed computed tomography hepatic angiography (CD-CTHA). This retrospective study included 186 HCC patients who received 90Y SIRT from May 2010 to June 2015 in a single institution. All procedures were performed in a hybrid angiography-CT suite equipped with digital subtraction angiography (DSA) and CD-CTHA capabilities. CD-CTHA was performed during pre-treatment hepatic angiography. 90Y SIRT was administered approximately 2 weeks later. Selective prophylactic embolization of extrahepatic vessels was performed if extrahepatic enhancement was seen on CD-CTHA or if an extrahepatic vessel opacified on DSA/CD-CTHA despite the final microcatheter position for 90Y microsphere delivery being beyond the origin of this vessel. Thirty-five patients (18.8%) required selective embolization of extrahepatic vessels. Technical success of 90Y SIRT was 99.5%. Two patients (1.1%) developed radiation-induced gastrointestinal ulceration, and one (0.54%) developed radiation-induced pneumonitis. Extrahepatic uptake of 90Y microspheres was seen in the gallbladder of one patient without significant complications. The use of CD-CTHA in 90Y SIRT of HCC was associated with a low rate of prophylactic embolization of extrahepatic vessels while maintaining a high technical success rate of treatment and low rate of complications. Level 4, case series.

History A 70-year-old man presented to the emergency department with fever, chills, rigors, and upper abdominal discomfort. Physical examination revealed jaundice and mild right upper quadrant tenderness. Laboratory tests revealed an increased C-reactive protein level of 133 mg/L (normal range, 0.2-0.9 mg/L), a white blood cell count of 11.69 ×109/L (normal range, 4-10 ×109/L), and an obstructive pattern on liver function tests, with a total bilirubin level of 3.5 mg/dL (59.9 µmol/L) (normal range, 0.4-1.9 mg/dL [6.8-32.5 µmol/L]), an alkaline phosphatase level of 716 U/L (11.9 µkat/L) (normal range, 39-99 U/L [0.65-1.65 µkat/L]), and an aspartate aminotransferase level of 88 U/L (1.47 µkat/L) (normal range, 12-42 U/L [0.20-0.70 µkat/L]). Serum amylase level was within normal limits at 84 U/L (1.40 µkat/L) (normal range, 38-149 U/L [0.63-2.48 µkat/L]). A clinical diagnosis of hepatobiliary sepsis due to ascending cholangitis was made. Relevant medical history included gastric carcinoma treated with a Billroth II surgical procedure 17 years earlier that was performed in conjunction with cholecystectomy. In addition, there were episodes of ascending cholangitis 6-12 months prior to the current admission that were managed conservatively with antibiotics at another institution. Blood cultures were positive for Klebsiella oxytoca. Administration of intravenous antibiotics was started, and CT examination of the abdomen was performed. Because a previous Billroth II procedure had been performed, the patient underwent percutaneous transhepatic cholangiography.

In light of the rising rate of incidentally detected subcentimetre thyroid nodules due to improved surveillance and diagnostic imaging, the decision of whether to perform fine needle aspiration cytology is increasingly pertinent. We aim to assess (1) the sampling adequacy of fine needle aspiration cytology, (2) malignancy rate, (3) thyroidectomy rate and (4) diagnostic accuracy of fine needle aspiration cytology. A total of 245 subcentimetre nodules in 220 patients underwent fine needle aspiration cytology between 2011 and 2014. Medical records were reviewed for cytology results, subsequent management and histopathological results in the event the patient underwent thyroidectomy. Sampling adequacy was calculated as the percentage of diagnostic results (Bethesda II–VI). Malignancy rate was defined as the percentage of Bethesda IV–VI diagnoses. Amongst patients with Bethesda IV–VI diagnoses who underwent thyroidectomy, their cytology reports were correlated with post-operative histopathological findings. The sampling adequacy of fine needle aspiration cytology was 77.1%. Malignancy rate (Bethesda IV–VI) was 9.7%. The respective malignancy rates in the

Purpose: Radiology global outreach programs have increased in recent years but progressed more slowly than other specialties. Establishing radiology services is increasingly recognized as a priority in resource-limited settings. Myanmar has a tremendous disease burden that is treatable with interventional radiology (IR) techniques, and aims to grow and effectively integrate this service into its public healthcare sector. Through collaborations between Asia Pacific Society of Cardiovascular and Interventional Radiology (APSCVIR) and Myanmar Radiological Society (MRS), the field of IR has grown exponentially over recent years. This study aims to provide a Myanmar national IR report on the current trends and future challenges. Methods and materials: Descriptive variables across five domains (facility and equipment, workforce, supplies, infrastructure, and casemix) from the four public sector hospitals with IR capability were obtained between 2016-2019. The four hospitals were Yangon General Hospital (YGH), Yangon Specialty Hospital (YSH), Mandalay General Hospital (MGH), and Defense Services General Hospital (DSGH). Data were analyzed to demonstrate progress in IR and the differing casemix. Results: There are currently four IR-capable hospitals and nine interventional radiologists across Myanmar’s public healthcare sector. IR case volumes tripled from 514 cases in 2016 to more than 1,500 cases in 2019. The three most common procedures performed were trans-arterial chemoembolization (TACE, 63%), bronchial arterial embolization (BAE, 7.7%), and drainages (7.7%). Significant challenges to the growth and adoption of IR services span the domains of infrastructure, equipment and supplies, workforce, and IR awareness, among other clinical specialties. Conclusion: Myanmar’s healthcare priorities, coupled with international radiological outreach programs, have led to rapid growth of IR. The exponential growth in case volumes is promising for Myanmar and other developing countries. But to widen the scope of practice and integrate the service within local clinical workflows, a holistic effort that addresses multiple domains is needed in the future.

Aim The long-term stress, anxiety and job burnout experienced by healthcare workers (HCWs) are important to consider as the novel coronavirus disease (COVID-19) pandemic stresses healthcare systems globally. The primary objective was to examine the changes in the proportion of HCWs reporting stress, anxiety, and job burnout over six months during the peak of the pandemic in Singapore. The secondary objective was to examine the extent that objective job characteristics, HCW-perceived job factors, and HCW personal resources were associated with stress, anxiety, and job burnout. Method A sample of HCWs (doctors, nurses, allied health professionals, administrative and operations staff; N = 2744) was recruited via invitation to participate in an online survey from four tertiary hospitals. Data were gathered between March-August 2020, which included a 2-month lockdown period. HCWs completed monthly web-based self-reported assessments of stress (Perceived Stress Scale-4), anxiety (Generalized Anxiety Disorder-7), and job burnout (Physician Work Life Scale). Results The majority of the sample consisted of female HCWs (81%) and nurses (60%). Using random-intercept logistic regression models, elevated perceived stress, anxiety and job burnout were reported by 33%, 13%, and 24% of the overall sample at baseline respectively. The proportion of HCWs reporting stress and job burnout increased by approximately 1·0% and 1·2% respectively per month. Anxiety did not significantly increase. Working long hours was associated with higher odds, while teamwork and feeling appreciated at work were associated with lower odds, of stress, anxiety, and job burnout. Conclusions Perceived stress and job burnout showed a mild increase over six months, even after exiting the lockdown. Teamwork and feeling appreciated at work were protective and are targets for developing organizational interventions to mitigate expected poor outcomes among frontline HCWs.

Introduction We aimed to study anxiety and burnout among Division of Radiological Sciences (RADSC) staff during the COVID‐19 pandemic and identify potential risk and protective factors. These outcomes were compared with non‐RADSC staff. Methods A cross‐sectional online study was conducted between 12 March and 20 July 2020 in the largest public tertiary hospital receiving COVID‐19 cases. Burnout and anxiety were assessed with the Physician Work‐Life Scale and the Generalized Anxiety Disorder‐7 Scale, respectively. Workplace factors were examined as potential risk and protective factors using multivariable ordinary least squares regression analyses, adjusting for pertinent demographic characteristics. Results RADSC staff (n = 180) and non‐RADSC staff (n = 1458) demonstrated moderate‐to‐severe anxiety rates of 6.7 and 13.2 % and burnout rates of 17.8 and 23.9 %, respectively. RADSC staff reported significantly lower anxiety (mean ± SD: 4.0 ± 3.7 vs 4.9 ± 4.5; P‐value

In this opinion piece derived from a webinar organized by the Radiological Society of North America and conducted in the spring of 2020 during the COVID-19 pandemic, leaders from three large North American and Asian academic radiology programs review the strategies employed at their respective institutions to address the impact of the pandemic on their departments. In the first segment, the author describes the approach taken in the radiology department at an 1800-bed Asian hospital system which focuses on the creation of capacity to accommodate over 5000 COVID-19 patients in early 2020, the sustaining of services during the surge, and the development of adaptive mechanisms to address future surges and pandemics. In the second segment, a large southwestern medical system addresses the creation of a long-term strategy to provide imaging services safely for staff and patients while simultaneously utilizing technology to maintain interprofessional connections. The final segment describes how a large multifacility health-care enterprise in the Pacific Northwest of the United States is developing strategies to successfully reemerge from the forced reduction in imaging services experienced during the COVID-19 surge in early 2020.

To describe rates and management strategies of arterial dissections in transarterial chemoembolization (TACE) and Yttrium-90 selective internal radiotherapy (This retrospective review included 1377 hepatic angiographies between May 2010 and June 2015 in a single centre for TACE andTwelve cases of arterial dissections (12/1377, 0.87%) were documented. Three dissections (3/633, 0.47%) occurred during TACE, seven (7/449, 1.56%) during pre-treatment planning angiographies (PTPA) forArterial dissection is a rare but important complication of transarterial locoregional therapy. Where possible, attempts should be made at completing the therapy. Deferring treatment can be considered as dissections usually heal within 3 months.Level 4, case series.

The coronavirus 2019 (COVID-19) outbreak poses a serious public health risk. To date, the disease has affected almost all countries in the world. The enormous scale of the outbreak and the relative lack of knowledge and information regarding a new virus, as well as the unpredictability of events, make it challenging for leadership teams to respond. This paper shares how we have reconfigured our radiology leadership team into a smaller disease outbreak task force (DOTF) to respond and coordinate all related efforts during this ongoing COVID-19 pandemic. The DOTF format is modelled after the military with domain groups looking at manpower, intelligence, operations, and logistics matters on a daily basis so that timely decisions can be made and action plans executed promptly. In managing the DOTF, discipline, flexibility, and teamwork are key principles, and these are built upon a strong foundation of focus on infection prevention and control, and patient and staff safety as well as staff well-being. The DOTF has positioned us well to confront the many challenges to date. We believe it will also help us navigate the complex issues that will arise with future surges in cases and in formulating strategies to manage exit from the present and future lockdowns. Key Points • In a pandemic, regular and directed meetings by a smaller leadership core group are required, for prompt decision making and execution of action plans. • The military format, with domain groups to look at manpower, intelligence, operations, and logistics matters, is useful in managing a pandemic. • Discipline, flexibility, and teamwork with strong focus on infection prevention and control, and patient and staff safety as well as staff well-being are key principles for leadership teams managing a pandemic.

The coronavirus disease 2019 (COVID-19) pandemic presents an unprecedented challenge to the health care systems of the world. In Singapore, early experiences of the radiology community on managing this pandemic was shaped by lessons learned from the severe acute respiratory syndrome outbreak in 2003. This article surveys the operational responses of radiology departments from six public hospitals in Singapore. © RSNA, 2020.

OBJECTIVE. This article shares the ground operational perspective of how a tertiary hospital radiology department in Singapore is responding to the coronavirus disease (COVID-19) epidemic. This same department was also deeply impacted by the severe acute respiratory syndrome (SARS) outbreak in 2003. CONCLUSION. Though similar to SARS, the COVID-19 outbreak has several differences. We share how lessons from 2003 are applied and modified in our ongoing operational response to this evolving novel pathogen.

International audience; The coronavirus disease 2019 pandemic has challenged and changed health care systems around the world. There has been a heterogeneity of disease burden, health care resources, and nonimaging testing availability, both geographically and over time. In parallel, there has been a continued increase in understanding how the disease affects patients, effectiveness of therapeutic options, and factors that modulate transmission risk. In this report, radiology experts in representative countries from around the world share insights gained from local experience. These insights provide a guidepost to help address management challenges as cases continue to rise in many parts of the world and suggest modifications in workflow that are likely to continue after this pandemic subsides.